Record # 1 A 39-year-old Polish man comes to the clinic for painful calves after walking long distances and

for discoloration of the fingers with changes in temperature. He says his symptoms started two months ago, and he gets no relief from the ibuprofen. He has previously been healthy. He currently smokes a pack a day and drinks socially. He has no history of drug abuse. On physical examination, his blood pressure is 140/90 mm Hg, heart rate is 68/min, and he is afebrile. Examination of the hands reveals distal digital ischemia and trophic changes in the nails of both hands. Radial pulses are absent bilaterally, but all other pulses are present. His right calf shows evidence of a superficial thrombophlebitis. Laboratory studies show: white cell count 9,600/mm3, hematocrit 38.6%, MCV 89 m3, ESR 40 mm/h, and C-ANCA as negative. The rheumatoid factor and ANA are negative. Which of the following should be done next for this patient? (A) Heparin (B) Prednisone (C) Arterial bypass (D) Cyclophosphamide (E) Abstention from tobacco Record # 2 A 25-year-old woman with Crohn's disease presents to your office with recurrent abdominal pain and diarrhea. She has been taking mesalamine 4 grams per day for the last year. Last fall, after developing diarrhea and pain, she was placed on prednisone 60 mg daily. She had a complete remission and, after a 3-month tapering of the prednisone, suffered a relapse. Prednisone was restarted 2 months ago at 60 mg daily, and now as the dose has decreased to 20 mg per day, the diarrhea has recurred. She is having 6 to 8 water stools per day, crampy pain, and some weight loss. What would be the best next step? (A) Restart the prednisone and plan to maintain the dose at 40-60 mg indefinitely (B) Restart the prednisone with 6-mercaptopurine and plan on prednisone taper in 2 months (C) Stop the prednisone and add cyclosporine (D) Admit to the hospital and give high-dose intravenous steroids to induce remission (E) Stop the mesalamine and add methotrexate Record # 3 A 65-year-old man presents to the emergency room with complaints of weakness, generalized swelling in his extremities, and right leg pain. At the time of presentation, he appears to be in moderate distress from the leg pain. The patient states that his symptoms started two days ago. The patient also has frequent urination and increased thirst. He states that he has felt weak for the past few months. Physical examination reveals a tender, erythematous, and swollen right calf. He also has 2+ pitting edema in all extremities. Blood pressure is 107/55 mm Hg, and temperature is 100.3 F. Venous ultrasound is positive for lower extremity deep vein thrombosis. Laboratory studies reveal: White cell count 11,000/mm3; hematocrit 32.3%; platelets 105,000/mm3; K 4.0 mEq/L; BUN 24 mg/dL; creatinine 1.7 mg/dL. The PT/PTT are normal. Total bilirubin 0.4 mg/dL, AST 28 U/L, albumin l.9 g/dL, cholesterol 326 mg/dL; triglycerides 425 mg/dL. Urine dipstick shows protein 3+, hemoglobin 1+, white cells 1+; 24-hour urine shows 6.2 grams of protein. What is the next step in the treatment of this patient? (A) Renal biopsy (B) Plasmapheresis (C) Anticoagulation (D) Cyclophosphamide (E) Prednisone Record # 4 A 42-year-old man from Vietnam, who had been a bus driver in Thailand, presents to the emergency department after having shortness of breath while playing soccer with his son this morning. Over the last several months, he has been having several episodes of shortness of breath. Several of the episodes were associated with chest pain. He denies any significant medical history. He has a 25-pack-year use of tobacco, and he has a sedentary lifestyle. His father had a myocardial infarction at the age of 59. His heart rate is 72/min, blood pressure is 140/66 mm Hg, and respiratory rate is 14/min. His examination shows mild jugulovenous distention with a collapsing carotid arterial pulse. His cardiac examination reveals a point of maximal impulse that is displaced laterally and inferiorly and a mild diastolic blowing murmur at the base while he sits up. His sensory examination shows loss of vibration sense in all extremities, and an abnormal Romberg test. EKG shows normal sinus rhythm with left axis deviation and ST-segment depression and T-wave inversion in leads I, aVL, V5, and V6. The chest x-ray shows an enlarged heart with dilatation of the proximal aorta. The CBC, chemistries, and cardiac enzymes are negative. The echocardiogram shows an ejection fraction of 60%. What is the next best step in the management of this patient? (A) Treat with digitalis (B) Exercise stress test (C) Cardiac catheterization (D) VDRL and lumbar puncture, followed by penicillin therapy (E) Aortic valve replacement Record # 5 A 40-year-old woman is brought to the emergency department by her daughter who states that she found her mother at home several hours ago, confused, lethargic, and unable to get up from her chair or speak. Her mother has a seizure disorder for which takes an antiseizure medication. She also has a history of alcohol abuse in the remote past. For the past several weeks, her mother has been complaining of difficulty sleeping and anxiety. The patient is stuporous and unresponsive to verbal stimuli. Her blood pressure is 100/60 mm Hg, heart rate is 50/min, and respiratory rate is 9/min. The pupils are pinpoint, and there is horizontal nystagmus. Asterixis is present. Laboratory examinations reveal: white cell count 9,800/mm3, sodium 150 mEq/L, BUN 18 mg/dL, creatinine 0.9 mg/dL, glucose 50 mg/dL, calcium 5 mg/dL, ammonia 100 g/dL, albumin 3.0 g/dL, AST 100 U/L, ALT 80 U/L. The urinalysis and lumbar puncture are normal. A CT scan of the brain shows cerebral edema. Arterial blood gas shows a pH of 7.20, a pCO2 of 46 mm Hg, and a pO2 of 79 mm Hg. Osmolar gap is zero. The toxicology screen is negative for benzodiazepines and opioids. What is the most likely substance that this patient overdosed on?

(A) Phenytoin (B) Carbamazepine (C) Valproic acid (D) Ethanol (E) Valium Record # 6 A 52-year-old woman presents to the emergency department with fever, weakness, and abdominal pain for the past three days. It has been associated with nausea and three episodes of vomiting. Her husband states that her temperatures have been as high as 103.5 F and that she has not been herself lately, appearing confused and lethargic. She has a history of hypothyroidism and migraine headaches. She appears lethargic, dehydrated, and is oriented only to person. Her blood pressure is 75/50 mm Hg, temperature is 102.9 F, and pulse is 108/min. She has dry oral mucosa and hyperpigmented areas of her skin spread diffusely over the posterior neck, hands, and knuckles. Rales are heard over the right lower lung field, and the chest x-ray shows a right lower lobe infiltrate. The EKG is normal. The patient is placed on intravenous hydration. Laboratory studies show a white cell count of 6,300/mm3, and the differential shows 82% neutrophils, 7% lymphocytes, and 9% eosinophils. The sodium level is 112 mEq/L, with a potassium of 5.9 mEq/L and a chloride of 92 mEq/L. Bicarbonate level is 20 mg/dL, and BUN is 32 mg/dL. The creatinine level is normal. The glucose level is 60 mg/dL, and the urinalysis is normal. What is the best initial test to diagnose this disorder? (A) Immediate cortisol and assess ACTH level (B) Metyrapone stimulation test (C) Early morning cortisol (D) A cosyntropin stimulation test (E) 24-hour urine cortisol Record # 7 A 45-year-old woman presents to your office after developing a pruritic rash and a fever. She first noticed it on her wrists two weeks ago but states that it has now spread to her feet as well. Her past medical history is significant for a seizure disorder following the removal of a meningioma. She has been treated with Dilantin. Physical examination is significant for icteric sclera. There are polygonal, flat-topped, violaceous papules limited to her wrists and her ankles. A white, reticulated, lacy lesion is also evident on examination of her buccal mucosa. Her liver is enlarged and is nontender to palpation. Laboratory analysis reveals: PT 11 seconds, albumin 3.6 g/dL, alkaline phosphatase 160 U/L, AST 700 U/L, ALT 960 U/L, ANA 1:160. Anti-hepatitis C virus (second generation) is negative; antihepatitis-B surface antibody (HBs) is positive; and anti-hepatitis-B core antibody (Hbc)is negative. She has an erythrocyte sedimentation rate of 20 mm/h and a cholesterol of 160 mg/dL. Anti-smooth muscle antibody test is negative, and an ultrasound of the abdomen is normal. What would you do next? (A) Start prednisone (B) Initiate interferon--2b therapy (C) Administer N-acetylcysteine (D) Stop Dilantin (E) Start methotrexate Record # 8 A 28-year-old female comes to the emergency department with a headache and fever. She has not had any recent infections, nor has she been exposed to any drugs. Her medical history is unremarkable. On examination, the patient appears lethargic. Her temperature is 100.5 F, pulse is 100/minute, blood pressure is 130/85 mm Hg, and respirations are 18/min. Her conjunctivae are yellowish, and scattered petechiae are noted on the lower extremities. The liver and spleen are not enlarged. Laboratory studies show the following results: WBC 12,000/mm3; hematocrit 27%; platelets 14,000/mm3; bilirubin 4.5 mg/dL; direct bilirubin 0.5 mg/dL; BUN 40 mg/dL; creatinine 3.5 mg/dL. PT, fibrinogen, and PTT are all normal. Her peripheral blood smear shows fragmented red blood cells. What is the most effective treatment for this patient? (A) Splenectomy (B) Glucocorticoids (C) Plasmapheresis (D) Intravenous immunoglobulins (E) Platelet transfusion Record # 9 A 58-year-old woman comes to your office. She is currently in atrial fibrillation and is asymptomatic. Her rate is 70/min. She denies hypertension, diabetes, and congestive failure. There is no other past medical history. What is the most appropriate management of this patient? (A) Warfarin and clopidogrel (B) Heparin followed by warfarin (C) Low-molecular-weight heparin (D) Aspirin (325 mg) daily (E) Warfarin to maintain an INR of 2 to 3 Record # 10 A 62-year-old man presents to your clinic complaining of four days of dysuria, frequency, and urgency. He feels slightly feverish and has had dull, lower-back pain for the past few months. He has had several episodes of the dysuria over the last several months. Each time he was given antibiotics for one week, and the symptoms resolved. Currently his temperature is 100.4 F. The genital examination is unremarkable, and the digital rectal examination reveals a nontender prostate, which is normal in size and consistency, with no palpable masses. After gentle massage of the prostate, a small amount of purulent discharge is extruded from the urethral meatus. The urine culture grows 100,000 colonies/mL of E. coli. Urine cultures from his prior symptomatic episodes also grew E. coli but only 10,000 colonies/mL. Which of the following is most appropriate? (A) Cystoscopy

(B) Ciprofloxacin and azithromycin orally once now (C) Trimethoprim/sulfamethoxazole for one week (D) Renal ultrasound (E) Ciprofloxacin for 4 to 6 weeks Record # 11 A 29-year old man comes to your office for a routine visit. His only complaint is leg pain after walking a three-block distance. He states that six months ago he was able to walk a longer distance without having to stop. His father died of a heart attack at the age of 44. His mother had diabetes mellitus, and she too died of a heart attack at the age of 47. His older brother, who is now 35 years old, had a stroke and underwent a carotid endarterectomy last year. The patient presents as a thin individual with a blood pressure of 135/70 mm Hg and a heart rate of 78/min. Physical examination findings are remarkable for the presence of multiple xanthelasmas on the face, chest, and upper back. There is bilateral, irregular, firm, and nodular thickening in the Achilles tendons and extensor tendons of the hands. This patient's medications include atorvastatin, gemfibrozil at maximum doses, and niacin, which was added to the regimen six months ago. He is maintaining a fat-free diet and exercises regularly. Laboratory test results show: total cholesterol 815 mg/dL, triglycerides 515 mg/dL, and HDL 55 mg/dL. The level of total cholesterol has increased by 15% since the last visit. What would you recommend to this patient? (A) Nutritionist consult (B) Stress test for detection of silent ischemia (C) Plasmapheresis (D) Liver transplantation (E) Increase the dose of statins as long as transaminases are within the normal range Record # 13 A 55-year-old man presents with abdominal pain and diarrhea for the past 3 months. He has also noticed a weight loss of 10 lb during this period. He denies nausea, vomiting, melena, or hematochezia. He consumes five to six beers each weekend, smokes half a pack of cigarettes a day, but has never used intravenous drugs. The past medical history is significant for osteoarthritis, newly diagnosed diabetes on a trial diet for 2 months, and recurrent duodenal ulcers found on four separate upper endoscopies. He takes diclofenac/misoprostol and famotidine 40 mg bid. Three years ago, he had taken triple antibiotics to treat H. pylori. He also tells you that tumors run in his family. His vital signs are normal. Physical examination is significant for mild epigastric tenderness to deep palpation without radiation. Routine labs ordered show: WBC 8,500/mm3, hemoglobin 13.4 g/dL, hematocrit 40.1%, platelets 256,000/mm3, amylase 155 U/L, sodium 141 mEq/L, potassium 4.2 mEq/L, chloride 106 mEq/L, CO2 23 mm Hg, BUN 15 mg/dL, creatinine 1.0 mg/dL, glucose 188 mg/dL, and calcium 11.2 mg/dL (elevated). What test would you order next? (A) Serum lipase (B) Upper endoscopy with biopsy (C) Abdominal ultrasound (D) Fasting serum gastrin level (E) Liver enzyme studies Record # 14 A slim, healthy 30-year-old woman is scheduled for a dental prosthodontic procedure and was sent for medical evaluation of a known history of mitral valve prolapse (MVP). The patient is a highly active individual and denies palpitations, chest pain, or shortness of breath. She admits to having a family history of heart disease, notably her father, who had died of a heart attack in his forties, and her mother, who had mitral valve prolapse. On physical examination, the patient is comfortable and has normal vital signs. Auscultation of the heart reveals a normal S1 and S2 and a prominent midsystolic click, which is accentuated in the standing position. No systolic murmur is appreciated. What is your overall assessment and plan for this patient? (A) Get an echocardiogram to evaluate mitral valve motion and blood flow prior to clearing her for the procedure (B) Prescribe empiric antibiotics for endocarditis prophylaxis and clear her for the procedure (C) Get a cardiology consultation prior to medical clearance because the patient has a significant family history of heart disease (D) Clear her for the procedure without endocarditis prophylaxis (E) Clear her for the procedure with endocarditis prophylaxis Record # 15 A 40-year-old man comes to the office because of pain in his right knee for the past three days. The patient denies fever, vomiting, or dysuria. He has no history of trauma but admits to prior episodes of pain, especially after binge drinking. It usually occurs in the knee, ankle, or big toe and is relieved somewhat by ibuprofen. He takes no medications and has no allergies. He has a 25-pack-year smoking history and drinks about half a case of beer when hanging out with friends. His mother developed the same symptoms at the age of 50. On examination, the right knee appears swollen, red, and tender to palpation and has a limited range of motion. You decide to aspirate the knee joint. Which of the following is most consistent with his diagnosis? (A) Positively birefringent, rhomboid-shaped crystals and 200 white cells/L (B) Bipyramidal crystals and 2,000 white cells/mL (C) Negatively birefringent, rhomboid-shaped crystals and 20,000 white cells/L (D) Cloudy and watery fluid with weakly positive birefringent crystals and 20,000 white cells/L (E) Watery fluid with strongly negative birefringent crystals and 20,000 white cells/L Record # 16 A 35-year-old man comes to the hospital after an episode of syncope. There were no preceding symptoms, and the patient recovered rapidly and completely with no residual effects. The patient did not have seizure activity during the episode. There is no history of heart disease and no previous episodes of syncope. The patient lives in rural Connecticut. His only previous medical problem was bilateral facial palsy several months ago. Currently, the physical examination is normal, except for a heart rate of 52/min. His blood pressure is normal. An EKG shows a sinus rhythm with Mobitz II second-degree heart block with a PR interval of 0.34 seconds. Echocardiogram is normal. He has a positive VDRL and a negative FTA. What is the most appropriate management of this patient? (A) Doxycycline in addition to electrophysiological studies

(B) Ceftriaxone in addition to pacemaker (C) Ceftriaxone in addition to prednisone (D) Ceftriaxone (E) Doxycycline in addition to permanent pacemaker Record # 17 A 21-year-old man with no significant past medical history presents to office with complaints of blood in his urine and mucosal bleeding while brushing his teeth. The patient complains of intermittent "ringing in the ears." He denies any drug or alcohol use. He has no family history of bleeding disorders. Petechiae are noted in the oral cavity, as is dried blood in the nostrils. Laboratory studies show the following: Hematocrit 32%; white blood cell count 8,000/mm3 with 60% neutrophils; platelet count 13,000; PT 13 seconds; PTT 28 seconds; LDH 1,200 U/L; elevated indirect bilirubin. Coombs' test is positive; abdominal examination is normal; and the peripheral smear shows spherocytes. What is the most likely diagnosis? (A) Alport's syndrome (B) Bernard-Soulier syndrome (C) Felty's syndrome (D) Thrombotic thrombocytopenic purpura (E) Evans' syndrome (F) Idiopathic thrombocytopenic purpura (ITP) Record # 18 A 31-year-old woman presents to the emergency department with three hours of shortness of breath. She had been walking her dog this afternoon and had not been outside for more than a few minutes before she began to feel chest tightness, wheezing, and a cough. She has not had any relief from her bronchodilators or steroid inhalers that she uses daily. She states that her daily activities have become affected by frequent episodes of shortness of breath that recur a few times during each week. These attacks can last days at a time, and she is afraid that her current medications are no longer of assistance to her. On physical examination, she has a temperature of 98.8 F, a pulse of 98/min, a blood pressure of 136/90 mm Hg, and a respiratory rate of 23/min. There is some evidence of hyperemia and secretions in the nasal passages bilaterally. She is using her accessory muscles to breathe, and wheezing is audible. Pulmonary function testing reveals an FEV1 of 68% of predicted, with a reduced FEV1/FVC ratio. This increases by 14% after high-dose bronchodilators are administered. Her peak expiratory flow was 158 L/min before bronchodilators were given. Arterial blood gases on room air are: pH 7.36, pCO2 48 mm Hg, and pO2 60 mm Hg. Chest x-ray shows evidence of hyperinflated lungs. The severity of this patient's clinical condition corresponds with which of the following classifications of asthma? (A) Moderate intermittent (B) Severe intermittent (C) Mild persistent (D) Moderate persistent (E) Severe persistent Record # 19 What is the appropriate mode of colorectal cancer screening for the following case? A 44-year-old man whose father died of colon cancer at age 77 and who is asymptomatic. (A) Colonoscopy now and every 10 years (B) Flexible sigmoidoscopy now and every 5 years (C) Colonoscopy at age 50 and every 10 years (D) Colonoscopy now and every 10 years (E) Stool occult cards every year; colonoscopy if positive (F) Colonoscopy at age 40 and every 5 years (G) Colonoscopy in 3 years (H) Colonoscopy in 1 year (I) Colonoscopy every 1 to 2 years Record # 20 A 69-year-old woman with a history of severe asthma is brought to the emergency department by her daughter because of severe lightheadedness. The patient also complains of worsening shortness of breath and progressive fatigue over the last year. For the last three months, the patient is able to walk only 2 to 3 blocks before developing a profound shortness of breath. She recently started using three pillows for sleep during the night. She denies chest pain and diaphoresis. The patient's daughter states that three weeks ago, her mother had a syncopal episode that lasted for two minutes on her way to the supermarket. At that time, she did not seek medical attention. The patient's current medications include lisinopril, digoxin, and furosemide. In the emergency room, her heart rate is 102/min, blood pressure is 115/70 mm Hg, and respiratory rate is 22/min. Physical examination reveals jugulovenous distension and bibasilar crackles. Heart auscultation demonstrates a diminished S1, a loud P2, and an S3 gallop. There is a 1+ pitting edema of both extremities. EKG shows normal sinus rhythm with several multifocal premature contractions (PVCs) and a four-beat run of ventricular tachycardia (VT) at a rate of 128/min. The echocardiogram reveals an ejection fraction below 25% and no evidence of aortic stenosis. The patient is admitted to the telemetry unit, and recordings show PVCs and 12 runs of nonsustained VT of 4 to 18 beats in duration during the first day. Which of the following is the most appropriate management at this time? (A) Increase the dose of digoxin (B) Start metoprolol (C) Start amiodarone (D) Cardiac catheterization (E) Perform electrophysiologic study

Record # 21 A 65-year-old man presents to the emergency department complaining of palpitations that started 20 minutes ago. He states he had a "heart attack" one year ago. He smoked for twenty years and has had diabetes for ten years. He watches his diet and takes aspirin and atorvastatin. On physical examination, you find a heart rate of 145/min, a blood pressure of 148/85 mm Hg, and a respiratory rate of 22/min. He has intermittent waves in his jugular veins consistent with canon "a" waves, and his lungs are clear. The S1 varies in intensity. The EKG shows that the QRS complex is approximately 0.16 seconds in duration, with dissociation of the p waves from the QRS complexes. All the QRS complexes are positively deflected in all leads. How would you treat this gentleman? (A) Verapamil (B) Cardioversion (C) Adenosine (D) Insert a pacing catheter (E) Procainamide Record # 22 A 36-year-old woman comes to your office claiming that she has been feeling generalized weakness, along with stiff hands, wrists, and knees upon awakening, which lasts about 2 hours. She has also had a 4-pound weight loss over the last 2 1/2 weeks and an itchy rash on her chest. She claims the symptoms began only 2 to 3 weeks ago, and they have been debilitating. The stiffness and pain are bilateral and symmetrical. The symptoms have caused her to be late to work and have interfered with her duties. She appears tired. Her vital signs are normal. There is a maculopapular, fine rash on her anterior chest wall, which is not restricted to the skin fold areas. There are no nodules. The lungs, heart, and abdomen are normal. Her extremities are not edematous, but there is tenderness upon palpation of wrists and knees but no effusions or joint deformity. There is no tenderness over the tendon sheaths. Laboratory studies show: white cell count 8,600/mm3, hematocrit 39.4%, platelets 215,000/mm3, BUN 8 mg/dL, creatinine 0.9 mg/dL, glucose 125 mg/dL, and calcium 8.6 mEq/L. The rheumatoid factor and ANA are negative. X-rays of the joints are normal. Which of the following is the most appropriate action? (A) Anti-double-stranded DNA (B) Ceftriaxone and doxycycline (C) Methotrexate (D) Intravenous immunoglobulin G (IgG) (E) Serum Parvovirus B19 IgM Record # 23 A 55-year-old woman comes to the clinic after being diagnosed with type 2 diabetes mellitus during a routine screening performed at work. She is currently asymptomatic and denies any history of frequent urination. On physical examination, you note a normal blood pressure. Her heart, lungs, and the remainder of the physical examination are within normal limits. When you ask the nurse to weigh your patient, you note her body mass index (BMI) to be 34. What is the next step in the management of this patient? (A) Begin intense insulin therapy (B) Begin glipizide (C) Begin pioglitazone (D) Begin acarbose (E) Begin metformin Record # 24 A 56-year-old man presents to the emergency department with complaints of dyspnea on exertion for the last three days. The patient is normally able to walk about eight blocks without any problems, but now can only walk one. He doesn't take any medications and denies alcohol and tobacco use. Vital signs are: temperature 98.7 F, pulse 126/min, blood pressure 124/68 mm Hg, and respirations 18/min. The jugulovenous pressure is elevated, and there is a soft diastolic rumble at the apex with an opening snap. Rales are present at both bases. EKG shows atrial fibrillation at a rate of 126/min. What is the next best step in the management of this patient? (A) Furosemide (B) Diltiazem (C) Transesophageal echocardiogram (D) Start coumadin (E) Mitral valvotomy (F) Electrical cardioversion Record # 25 A 51-year-old man is admitted to the hospital with the acute onset of hypotension, generalized weakness, and confusion. He has experienced progressive shortness of breath over the past two years, which occurs now even on minimal exertion. He has a history of multiple transient ischemic attacks (TIAs), a pulmonary embolus last year, and a chronic deep venous thrombosis (DVT). Evaluation for a hypercoagulable state was unrevealing. He has been on coumadin over the last year. His temperature is 100.2 F, blood pressure is 80/20 mm Hg, and pulse is 104/min. His skin is hyperpigmented. There is jugular venous distention and small testicles. He has a systolic murmur heard over the third to fourth intercostal space, along the left sternal border. On lung auscultation, there are crackles bilaterally, and the liver edge is palpable 3 cm below the right costal margin. There is bilateral leg edema, and the stool is guaiac-positive. His white cell count is 16,800/mm3. Other laboratory tests show: sodium 122 mEq/L, potassium 5.5 mEq/L, glucose 48 mg/dL, calcium 11.3 mg/dL, BUN 88 mg/dL, and creatinine 2.2 mg/dL. His prothrombin time is 34 seconds, INR is 4.5, and partial thromboplastin time is 64 seconds. The albumin level is 1.2 g/dL, and hematocrit is 28%. What would be most important initial step in the management of this patient? (A) Order blood transfusion and start normal saline (B) The cosyntropin stimulation test (C) Send blood for cortisol and treat with hydrocortisone and normal saline (D) Send blood and sputum cultures and start broad-spectrum antibiotics (E) Vitamin K and fresh frozen plasma

Record # 26 A 28-year-old woman presents to your office complaining of fatigue, weakness, anorexia, arthralgias, and some oral ulcers that interfere with eating. She also has been seen by a dermatologist for treatment of an erythematous rash that gets worse with sun exposure. All of these symptoms have been developing slowly over the past several months. Her past medical history is significant a positive PPD, for which she has been taking isoniazid. She also had Wolff-Parkinson-White syndrome, which is being treated with procainamide. She has had two brief episodes of confusion over the past few months that had resolved spontaneously. There is maculopapular rash on the areas exposed to the sun. Her ANA is positive. The hematocrit is 33.1%, platelets are 112,000/mm3, BUN is 32 mg/dL, and creatinine is 2.2 mg/dL. Her urinalysis shows 2+ protein and some red cell casts. What is the next best step? (A) Antibody to single-stranded DNA (B) LE cell preparation (C) Antihistone antibodies (D) Renal biopsy (E) Antimitochondrial antibody Record # 27 A 22-year-old man with a known family history of hypertrophic obstructive cardiomyopathy (HOCM) presents to the emergency department with an episode of syncope while climbing the stairs to get to his third-floor apartment. He was started on a beta-blocker twelve months ago but continued to have symptoms of dyspnea and lightheadedness. Verapamil was added six months ago, but he still has had persistent symptoms. What would be the next best step in the management of this patient? (A) Cardiac transplantation (B) ACE inhibitors (C) Electrophysiology studies (D) Surgical myomectomy (E) Injection of absolute alcohol into the myocardium Record # 28 A 25-year-old white woman comes to your office today to meet you for the first time. Her only complaint is of headaches. Her blood pressure is 160/105 mm Hg in both arms. She is obese and otherwise has a normal physical examination with no bruits in her abdomen. Two weeks and three weeks later, her blood pressure remains elevated at 155/107 and 157/105 mm Hg, respectively. She smokes but does not drink alcohol. Laboratory studies show: Sodium 138 mEq/L, potassium 4.7 mEq/dL, BUN 14 mg/dL, creatinine 0.8 mg/dL. Urinalysis reveals +1 protein, with no red or white cells. What is the next step to confirm a diagnosis? (A) Doppler (duplex) ultrasound of the kidneys (B) Start lisinopril (C) Magnetic resonance imaging (MRI) of the abdomen (D) Captopril renography (E) Angiography Record # 29 A 72-year-old white man is seen in the clinic with complaints of increasing dyspnea on exertion and orthopnea. The patient recently moved to the city and has records of a recent hospitalization four months ago for dyspnea upon minimal activity, increasing fatigue, and orthopnea. The patient has a long-standing history of asthma and diabetes. Medications at this time include inhaled steroids, inhaled beta-agonists, and glyburide. ACE inhibitors and furosemide were started two months ago. Vital signs are: pulse 100/min, respirations 24/min, and blood pressure 154/94 mm Hg. Cardiovascular examination reveals a regular rate and rhythm, and an S4 is present. Bibasilar crackles are evident in the chest. There is no wheezing. There is a trace bilateral pedal edema in the extremities, and routine labs are normal, except for a BUN of 42 mg/dL and a creatinine of 1.9 mg/dL. An EKG shows a sinus rhythm with left ventricular hypertrophy. Chest x-ray shows cardiomegaly and increased vascular congestion. Labs four months ago showed a BUN of 27 mg/dL and a creatinine of 1.2 mg/dL. Echocardiogram shows left ventricular hypertrophy and an ejection fraction of 57%. What is the next step in management in the management of this patient? (A) Increase the dose of furosemide (B) Restrict salt and fluids and reschedule a return appointment in four weeks (C) Increase the dose of ACE inhibitors (D) Add digoxin (E) Start the patient on carvedilol Record # 30 A 44-year-old man undergoes an upper endoscopy for chronic heartburn. He has had no nausea, vomiting, dysphagia, fever, chills, or weight loss. The heartburn occurs three to four times per week. He has a long history of tobacco but no alcohol use. An upper endoscopy shows erosive esophagitis and 4 cm of Barrett'sappearing mucosa. Biopsies are taken. Which of the following statements concerning this patient is false? (A) H2 blockers at standard doses are minimally effective in treating GERD (B) The risk of developing esophageal cancer is related to the histology on biopsy (C) The risk of developing esophageal cancer is approximately 0.5% per year (D) There is clear evidence that an endoscopy every year for surveillance will decrease morbidity and mortality (E) A proton-pump inhibitor daily should be prescribed Record # 31 A 64-year-old woman presents to the emergency department with complaints of slurred speech, blurry vision, and numbness of the left upper extremity that

lasted about ten to fifteen minutes this morning. The patient had similar symptoms two days earlier. Her past medical history is significant for recently diagnosed cirrhosis, for which she is taking spironolactone. Vital sign are: temperature 98.7 F, pulse 72/min, blood pressure 142/78 mm Hg, and respiratory rate 14/min. Laboratory studies reveal: White cell count 7,600/mm3, hematocrit 38.9%, prothrombin time (PT) 11.4 seconds, INR 1.0, partial thromboplastin time (PTT) 37.8 seconds. An EKG shows atrial fibrillation at a rate of 78/min. What is the next best step in the management of this patient? (A) Echocardiogram (B) Diltiazem (C) Electrical cardioversion (D) Heparin 5,000 U bolus, then start heparin drip (E) ASA 325 mg daily (F) Coumadin Record # 32 A 40-year-old woman presents with severe epigastric pain, nausea, and vomiting. The pain began suddenly and radiates to the back. Physical examination shows normal vital signs. However, she is icteric. The abdomen is tender, especially in the epigastrium. Laboratory studies show the following: amylase 3,990 U/L, ALT 220 U/L, AST 180 U/L, total bilirubin 0.5 mg/dL, and albumin 3.5 g/dL. An abdominal ultrasound shows numerous gallstones in the gallbladder. Which of the following statements concerning this patient is false? (A) At admission, a Ranson score of 1 rules out the possibility of severe disease (B) Intravenous fluids should be given at a rate of greater than 250 mL per hour for several liters (C) A nasogastric tube is not necessary (D) A CT scan is not required to confirm the diagnosis (E) A cholecystectomy should be performed prior to discharge Record # 33 A 41-year-old woman comes to clinic with hair loss for the past month and energetically asks you to refer her to a "hair specialist." She denies cough, fever, or weight change but mentions that she has constantly felt tired and has had difficulty concentrating lately. She also has frequent headaches and muscle cramps. Her menstrual cycle is usually regular, but now she has been having amenorrhea for the past L, and the viraltwo months. She is HIV positive, her CD4 count is 78/ load is undetectable. She also has a history of atrial fibrillation, which has required defibrillation several times. Sotalol, procainamide, and quinidine have been ineffective in maintaining her sinus rhythm in the past. She is on zidovudine, lamivudine, nelfinavir, trimethoprim/sulfamethoxazole, and amiodarone. She smokes half a pack of cigarettes a day. On physical examination, she is slightly overweight and has a temperature of 98.9 F, a respiratory rate of 16/min, and a blood pressure of 100/50 mm Hg. Her skin is pale and dry. Her hair is dry, but no obvious thinning is noticeable. The thyroid-gland lobes and isthmus are palpable, and nodular changes are not detected. Her ALT is 20 U/L, and the AST is 22 U/L. Thyroid-stimulating hormone (TSH) is 22 mU/L (normal 0.4-5 mU/L), free T4 is 0.4 ng/dL (normal 0.9-2.4 ng/dL), and T3 is 110 ng/dL (normal 70-130 ng/dL). The serum beta HCG is undetectable. Her EKG shows sinus rhythm. What would you advise for this patient? (A) Switch the trimethoprim/sulfamethoxazole to aerosolized pentamidine (B) Discontinue everything (C) Add azithromycin and levothyroxine (D) Stop the amiodarone (E) Change antiretroviral medications (F) Start levothyroxine Record # 34 A 75-year-old man is brought to the hospital after he was found lying on the floor of his apartment. On admission the patient talks and tells his story to the physician in the emergency room. He says that he is very sad because he lost his sister two days ago. The family denies this happening. The patient looks confused, weak, and dehydrated. His temperature is 100.5 F, with a pulse of 100/min and a blood pressure of 100/60 mm Hg. He has crackles over the right lung fields and bruises on the outer aspect of the right thigh. There is no fracture palpated, and the skin is intact. His sodium is 150 mEq/L, BUN is 45 mg/dL, and creatinine is 2 mg/dL. The urinalysis is positive for myoglobin, and there is an increased specific gravity. The dipstick is positive for blood, but on microscopic examination there are no red cells. The head CT scan shows old, lacunar infarctions. The patient is transferred to the floor for observation and treatment. During the night, the patient becomes more disoriented and agitated, and the nurse asks the intern for a restraint order, but the intern decides to give the patient intramuscular haloperidol. Which of the following is the most urgent step? (A) Keep the room dark and quiet (B) Electrocardiogram (C) Switch the haloperidol chlorpromazine (Thorazine) (D) Increase the dose of the haloperidol (E) Add lorazepam Record # 35 A 21-year-old white man comes to the emergency department because of muscular weakness. He has had episodes of weakness for the past year. After coming home from the gym, he feels the inability to reach the cabinets in the kitchen. Sometimes he is unable to rise from a seated position. The attacks occur approximately 3 times per week, last 3 hours, and subside spontaneously. The attacks also occur after heavy meals. On physical examination, you note 2/5 motor strength in the bicep muscles bilaterally, with 3/5 strength of the handgrip, and 2/5 motor strength of the quadriceps bilaterally, with 4/5 strength on dorsiflexion of the feet. He has no prior medical history. Laboratory studies reveal: Sodium 140 mEq/L; potassium 2.0 mEq/L; chloride 112 mEq/L; bicarbonate 15 mEq/L; BUN 10 mg/dL, creatinine 0.8 mg/dL. What is the next best step in the management of this patient? (A) Repeat potassium level (B) Potassium chloride orally (C) Acetazolamide (D) Potassium chloride intravenously (E) Spironolactone

Record # 36 Mr. Njuki, a 25-year-old man recently emigrated from Nigeria, comes to your clinic complaining of worsening exertional shortness of breath. His symptoms have worsened over the last several months and include three-pillow orthopnea, paroxysmal nocturnal dyspnea, and nocturia. Mr. Njuki denies any resting or exertional chest pain at this time. Vital signs are: temperature 98.6 F, blood pressure 120/80 mm Hg, heart rate 75/min and irregular, and respirations 16/min. Physical examination is significant for jugular venous distention (JVD) worsening on inspiration, an S3 gallop with 3/6 systolic murmur radiating to the axilla, bibasilar crackles, and 1+ lower extremity edema bilaterally. EKG shows atrial fibrillation at rate of 72 per minute. Pulmonary congestion and an enlarged heart size are seen on chest x-ray. Echocardiogram is significant for reduced left ventricular systolic function, an ejection fraction of 22%, and decreased myocardial wall thickness. Which of the following will result in the greatest decrease in mortality? (A) Furosemide (B) Amiodarone (C) Beta-blocker (D) Digoxin (E) Spironolactone Record # 37 A 65-year-old man presents to your clinic for a second follow-up visit. Two months ago, he was hospitalized for an acute myocardial infarction. He currently denies chest discomfort, palpitations, shortness of breath, fever, or cough. His past medical history is significant for hypertension and hypercholesterolemia. He quit smoking three weeks ago after a 30-pack-year smoking history. Physical examination reveals a II/VI systolic murmur at the apex with a diffuse and displaced apical impulse. No jugulovenous distension, rubs, or peripheral edema is noted. The lungs are clear bilaterally. Blood pressure is 157/98 mm Hg, respirations are 16/min, pulse is 70/min, and temperature is 98.7 F. EKG shows a sinus rhythm at 68 bpm. Q waves are noted in leads V1-V3, along with 1 mm of ST-segment elevation in the anterior leads, unchanged from his last office visit three weeks ago. Laboratory studies show: sodium 141 mEq/L, potassium 4.1 mEq/L, chloride 109 mEq/L, CO2 25 mEq/L, BUN 11 mg/dL, creatinine 0.8 mg/dL, ESR 26 mm/h, WBC 8,200/mm3, hemoglobin 14 mg/dL, hematocrit 41%, and platelets 229,000/mm3. What is the most likely diagnosis? (A) Anterior wall myocardial infarction (B) Ventricular aneurysm (C) Dressler's syndrome (D) Right heart failure (E) Pericarditis Record # 38 A 34-year-old woman with severe heartburn presents for treatment. She reports heartburn 3 to 4 times per week but no dysphagia, nausea, or vomiting. She has a busy lifestyle and works 80 hours per week. She consumes one meal per day in the evening. However, she has been gaining weight over the past year. Although she smokes one pack of cigarettes per day, she is physically active. There has been no hospitalizations or surgeries. What would be the most appropriate course of treatment? (A) Proton-pump inhibitors daily for 3 months (B) Lifestyle modification (C) An upper endoscopy (D) Upper gastrointestinal series (E) 24-hour pH Record # 39 A 30-year old woman comes to your office for evaluation of deep venous thrombi. Last year she developed a lower extremity venous clot. She was on oral contraceptives but has subsequently stopped. She was successfully treated with coumadin for six months. Three weeks ago she developed a femoral venous thrombosis, and now she is again treated with coumadin. Her mother died of a pulmonary embolus, and her aunt on her mother's side had a history of venous thrombosis. All routine laboratory studies are normal, including the complete blood count, prothrombin time, activated thromboplastin time, and liver function tests. She has a test that is positive for the factor V leiden mutation by polymerase chain reaction (PCR). What will you recommend to the patient? (A) Coumadin for another three months (B) Low-molecular-weight heparin for six months (C) Intravenous heparin, then coumadin for six months (D) Lifelong coumadin (E) Inferior vena cava filter placement Record # 40 A 36-year-old man comes to the HIV clinic for a regular follow-up visit. He has been known to be HIV positive for three years. Antiretroviral treatment was started six months ago. His present regimen includes zidovudine, lamivudine, nelfinavir, azithromycin, and Bactrim (trimethoprim/sulfamethoxazole). He tolerates his medications well and claims to be compliant. After three months of therapy, there was a one-log reduction in his viral load, and the CD4 count increased from 45 to 285/L. At the present time, his blood tests show a rise in viral load back to the initial level. There is moderate truncal obesity and facial thinning. Laboratory studies show: ALT 112 U/L, AST 98 U/L, cholesterol 240 mg/dL, and triglycerides 260 mg/dL. What is the next step in treatment of this patient? (A) Continue the same medications (B) Repeat HIV viral load in three months (C) Genotypic analysis of a viral isolate (D) Assess serum drug concentrations (E) Change medications to stavudine, didanosine, and ritonavir

Record # 41 A 29-year-old woman with a history of systemic lupus erythematous (SLE) for the last 4 years comes for evaluation of malaise, nausea, vomiting, and depression. She currently denies joint pain. Three years ago, the patient was given steroids but stopped them on her own when she became pregnant. Upon examination, the patient has a heart rate of 84/minute and a blood pressure of 162/98 mm Hg. Laboratory studies show a hematocrit of 27.4%, with a serum creatinine of 3.7mg/dL and potassium of 4.9 mEq/L. Her urinalysis has 2+ protein and 25-50 red blood cells/hpf. Regarding renal biopsy, which one of the following is the best answer? (A) It is not indicated in this patient (B) It is mandatory in a patient with positive lupus serology to rule out lupus nephritis (C) Biopsy is used to determine the need for cyclophosphamide (D) It is indicated only in relapse patients (E) It is indicated in drug-induced lupus Record # 42 A 38-year-old stockbroker presents to the emergency room with complaints of several episodes of headaches for the past few days, which have worsened over the past two hours. He had an initial relief of pain with indomethacin, but the pain has now significantly worsened. The patient attributes the headache to stress and excessive alcohol intake over the past few days. He describes the pain as unilateral, mainly in the orbital region, with watering of the eyes, swelling of the eyelids, and nasal congestion. The patient had infrequent headaches of a similar kind in the past, which were relieved with acetaminophen. He was symptomfree for the past six months. He denies taking any other medications. On examination, vital signs are in the normal range. Detailed physical and neurological examinations are normal. The patient is initially given 100% oxygen via a facemask. What is the next step in the management of this patient to relieve his pain? (A) High doses of acetaminophen (B) Sumatriptan 6 mg subcutaneously stat (C) Lithium (D) Verapamil 80 mg stat and every 8 hours (E) Prednisone 60 mg stat Record # 43 A 51-year-old man comes to the clinic complaining of the inability to perform his daily activities because of weakness and fatigability in his extremities, especially his legs, for the past three weeks. He also has a cough productive of blood-tinged sputum for the last two months. His other past medical history is unremarkable. He has smoked one pack of cigarettes a day for over thirty years. He has lost about 20 pounds over the last month. Physical examination reveals: temperature 98.7 F, blood pressure 140/80 mm Hg, heart rate 88/min, and respiratory rate 16/min. Lungs are clear to auscultation. On neurologic exam, the cranial nerves are intact. Muscle strength in the extraocular muscles is intact. Muscular strength in the extremities is decreased to 4/5, and the weakness is more pronounced in the proximal muscle groups. His strength increases after several minutes of repetitive exercise. A chest x-ray reveals a 2-cm lesion in the left upper lobe with hilar and mediastinal lymph-node enlargement. The initial complete blood count and chemistry panel are unremarkable. Tensilon (edrophonium) test is of questionable effect. An EMG is ordered, and the anti-acetylcholine receptor antibody level is pending. What will be the most effective treatment of this patient's neurologic condition? (A) Pyridostigmine (B) Thymectomy (C) Prednisone (D) Plasmapheresis (E) Chemotherapy and radiation Record # 44 A patient comes to the hospital with 1 to 2 hours of crushing substernal chest pain and ST-segment depression in V2-V4. He has a history of peptic ulcer disease and diabetes. He currently has melena. Which of the following will result in the greatest decrease in mortality? (A) Angioplasty (B) Metoprolol (C) Captopril (D) Nitrates (E) Emergency bypass (F) Tirofiban (G) Heparin (H) Aspirin Record # 45 What is the appropriate mode of colorectal cancer screening for the following case? A 77-year-old man who had a hemicolectomy last month for colon cancer and who has no family history of colon cancer. (A) Colonoscopy now and every 10 years (B) Flexible sigmoidoscopy now and every 5 years (C) Colonoscopy at age 50 and every 10 years (D) Colonoscopy now and every 10 years (E) Stool occult cards every year; colonoscopy if positive (F) Colonoscopy at age 40 and every 5 years (G) Colonoscopy in 3 years (H) Colonoscopy in 1 year (I) Colonoscopy every 1 to 2 years Record # 46

A 27-year-old man gets a PPD skin test as he starts his medical residency. He is originally from India and has never been tested before. He has 12 mm of induration and a normal chest x-ray. He had BCG vaccination as a child and a booster at the age of 24. What should be your next step? (A) You apologize for doing the test and say, "Oops! People with previous BCG vaccination should not be PPD tested!" (B) Check three sputum acid-fast stains (C) Repeat the PPD the following year (D) Give him isoniazid and vitamin B6 for nine months Record # 47 A 62-year-old man presents to the emergency department with palpitations and lightheadedness for the past 5 days. He was previously healthy. He denies a previous stroke or diabetes. He has had hypertension for the last 10 years, which has been controlled on medication. On examination, he is found to have an irregularly irregular pulse of 120/min and a blood pressure of 98/70 mm Hg. The rest of the examination is normal. His laboratory tests are significant only for a creatinine level of 2.3 mg/dL. An EKG shows a rate of 132/minute with an irregularly irregular rhythm. The QRS is 90 milliseconds in duration. The ST segments and T waves are normal. Which of the following is the most appropriate initial therapeutic option? (A) Electrical cardioversion (B) Ibutilide (C) Metoprolol (D) Amiodarone (E) Low-molecular-weight heparin Record # 48 A 23-year-old healthy woman presents to your office for an annual physical examination. She has a history of a seizure disorder, which is well controlled on valproic acid. She feels well today. Two years ago, she delivered a child with meningocele during her first pregnancy. She is concerned about the recurrence of this event in a future pregnancy. Her physical examination is normal, and the urine pregnancy test is negative. What should you tell her? (A) The risk of recurrence in a future pregnancy is not increased compared with the general population (B) The risk is higher compared with the general population, but nothing can decrease it (C) She should take folic acid 0.4 mg daily in the second trimester of pregnancy, and this will significantly decrease the risk of having her next child born with a neural-tube defect (D) She should take folic acid 4 mg daily prior to conception and in the first several months of pregnancy (E) All seizure medications should be ceased prior to the pregnancy Record # 49 A 48-year-old man with AIDS comes to clinic for a regular follow-up. He was recently started on zidovudine (AZT or ZDV), lamivudine, and nelfinavir. He was previously seen by a different doctor in the clinic. The patient states that his viral load is now undetectable. His white count is 1,200/mm3 with 75% neutrophils. Six months ago, his viral load was 65,000, and his white cell count was 7,500/mm3 with 65% neutrophils. What is the most appropriate action at this time? (A) Switch lamivudine to didanosine (B) Switch nelfinavir to efavirenz (C) Start colony-stimulating factor (D) Bone-marrow biopsy (E) Switch the zidovudine (AZT) to stavudine Record # 50 A 43-year-old man presents to the clinic with complaints of fever, night sweats, anorexia, cough, and chest pain. The chest x-ray reveals infiltrates in both the lower and upper lobes, with possible cavitations in the apices. A presumptive diagnosis of tuberculosis is made on the basis of finding acid-fast bacilli (AFB) on microscopic examination of sputum. The patient is started initially on isoniazid, rifampin, pyrazinamide, and ethambutol. What is the best way to monitor this patient? (A) Sputum acid-fast stains every month for 6 months (B) Sputum cultures every month until cultures become negative (C) Serial chest x-rays (D) Blood testing for drug toxicity (E) Observe for clinical deterioration Record # 51 A 62-year-old man presents with complaints of progressive weakness and fatigue for the past three months. He also has had fever up to 101.1 F, shortness of breath, and a cough with yellowish sputum for the past five days. Yesterday he developed painful lesions of the upper lip. The physical examination reveals that he is thin with pale skin and multiple ecchymoses on the upper and lower extremities. The upper lip is significantly swollen and erythematous, with several vesicular lesions. The throat is erythematous. Lung auscultation reveals rales at the left base, with some dullness on percussion over the left lung base. The spleen is palpable at the level of 3 cm below the left costal margin. Chest x-ray reveals a left lower lobe infiltrate. A complete blood count shows: white blood cells 1,000/mm3, neutrophils 42%, lymphocytes 45%, monocytes 1%, eosinophils 12%, hemoglobin 8.0 g/dL, hematocrit 25.2%, mean corpuscular volume (MCV) 80 m3, and platelets 45,000/mm3. The bone marrow aspirate was unsuccessful for three attempts, but eventually a biopsy was obtained. The pathology report shows a mildly increased cellular content but no blasts with a moderate degree of fibrosis. What test would be most helpful in establishment of this patient's diagnosis? (A) Peripheral smear (B) Prussian blue staining (C) Leukocyte alkaline phosphatase

(D) Staining with tartrate-resistant acid phosphatase (E) Chromosomal analysis Record # 52 A 68-year-old man presents to hospital with complaints of worsening fatigue for the past few weeks. Two months ago, his nephrologist started him on erythropoietin after dialysis. He has been on hemodialysis for the past 19 years because his type II diabetes was never controlled. He denies chest pain or dizziness but reports feeling "awfully winded after I walk for one block." He also denies melena, hematochezia, or other bleeding. His medications include insulin, phosphate binders, and amlodipine. On physical examination, he appears pale and tired. His temperature is 98.9 F, and respirations are 18/min. When seated, his blood pressure is 140/72 mm Hg, and his pulse is 96/min. When standing, his blood pressure becomes 148/80, and pulse becomes 98/min. Heart and lung sounds are normal, and his abdomen is benign. Rectal examination reveals a trace guaiac-positive stool. Laboratory studies show: CBC: WBC 8,000/mm3; hemoglobin 9.5 mg/dL; hematocrit 31%; platelets 320,000/mm3. MCV 72 FL (normal 82-98 FL); MCHC 30 g/dL (normal 32-36 g/dL); RDW 17% (normal 13-15 %) Reticulocyte count (corrected) 1% Serum iron: decreased Ferritin 12 ng/mL (normal 15-200 ng/mL); TIBC elevated Bilirubin 0.4 mg/dL; direct bilirubin 0.2 mg/dL EKG: no new ST-T wave abnormalities, no Q waves Chest x-ray: borderline cardiomegaly What is the next best step in the management of this patient? (A) Ferrous sulfate (B) Blood transfusion (C) Colonoscopy (D) Increase the erythropoietin dose (E) Bone marrow biopsy Record # 53 A 52-year-old woman is brought to the emergency room by an ambulance after being found at home lying on the bedroom floor. The paramedic accompanying her hands you an empty medication bottle of nortriptyline. A neighbor who comes with her states that the patient has had a previous history of seizures, depression, and multiple suicide attempts. They were together just two hours prior to the incident. The patient is obtunded and only responds to painful stimuli. Examination reveals dilated and equally reactive pupils, flushed skin, and generalized muscle twitching. The abdominal examination reveals hypoactive bowel sounds. Her blood pressure is 72/48 mm Hg, the respiratory rate is 22/min, pulse is 68/min, and temperature is 102.5 F. The EKG shows a prolonged QT interval. What is the next best step in the management of this patient? (A) Immediate emesis with ipecac (B) Bicarbonate (C) Ceftriaxone and vancomycin (D) Activated charcoal (E) Hemodialysis Record # 54 A 62-year-old man presents to the emergency room with 13 hours of sharp, retrosternal chest pain radiating to the back. The patient states that he had a myocardial infarction two weeks ago. He did not have symptoms of shortness of breath at that time. He is currently experiencing increased chest pain on deep inspiration, which did not occur before. He first began to experience the pain while lying down. On physical examination, the patient has a low-grade temperature of 100.9 F, a pulse of 91/min, blood pressure of 110/74 mm Hg, and respirations of 23/min. The EKG displays Mobitz type I second-degree heart block, ST elevation in leads I, II, III, aVF, aVL, and V1-V6, and depressed PR intervals. His past medical history is significant for congestive failure and asthma with multiple hospitalizations requiring intubation. Laboratory studies reveal: WBC 16,000/mm3, hematocrit 38.8%, platelets 339,000/mm3, erythrocyte sedimentation rate 130 mm/h. What is the best initial treatment for this patient's condition? (A) Intravenous metoprolol or propranolol (B) Thrombolytics and admit to CCU for monitoring (C) Pacemaker (D) Nonsteroidal antiinflammatory drugs (NSAIDs) (E) Prednisone Record # 55 A 27-year-old woman is admitted to the hospital with complaints of lower abdominal pain, mucoid vaginal discharge, nausea, and vomiting for three days. She denies skin and mucosal lesions or dysuria. Her last menstrual period was two weeks ago. Her temperature is 101.4 F. She has tenderness in the right lower abdominal quadrant. The pelvic examination shows bilateral adnexal tenderness and pain with cervical motion. There is a cloudy mucoid discharge from the cervix. The pregnancy test is negative. Gram stain of the cervical discharge shows whites cells with no organisms, and the culture is pending. The patient is started on appropriate antibiotics. Which test would you do next to confirm the diagnosis? (A) DNA probe test (B) Vaginal ultrasonography (C) Laparoscopy (D) Ligase chain reaction (LCR) assay (E) Direct immunofluorescence assay

Record # 56 You are asked to evaluate a 62-year-old man on the orthopedic surgery service for shortness of breath. The patient was initially admitted to the hospital 14 days

ago for a right hip fracture and successfully underwent hip replacement surgery 12 days ago. He required treatment for congestive heart failure secondary to excessive postoperative fluid resuscitation. Three days ago, he once again developed shortness of breath and has been progressively worsening without a response to diuretics. The patient is tachypneic but able to complete sentences. His blood pressure is 137/83 mm Hg, respiratory rate is 26/min, and his heart rate is 108/min. An arterial blood gas on a 50% facemask shows a pH of 7.38, a pCO2 of 30 mm Hg, a pO2 of 72 mm Hg, and a saturation of 90%. The chest x-ray shows mild right basilar atelectasis without signs of congestion. The EKG shows sinus tachycardia with left ventricular hypertrophy, although there is right axis deviation. An echocardiogram estimates the pulmonary artery systolic pressure at 45 mm Hg. The venous duplex reveals bilateral chronic and acute nonocclusive femoral and popliteal thrombi with freely mobile clots. Intravenous heparin is started. What is the most urgent step in the management of this patient? (A) Spiral CT scan of the chest (B) V/Q scan (C) Intubate and place the patient on mechanical ventilation (D) Inferior vena cava filter placement (E) Initiate coumadin therapy (F) Embolectomy Record # 57 A 76-year-old man who was a smoker for the past 30 years with a history of chronic obstructive pulmonary disease (COPD) presents to the emergency department with a low-grade fever and increasing cough for the past three days. He also complains of shortness of breath for the past 48 hours. He worked as a nurse for 30 years and had a chronic hepatitis B infection for which he received interferon-2-alpha for 16 weeks and tolerated it well. During the physical examination, he has a large loose stool and appears acutely ill and confused. His temperature is 101 F, respirations are 24/min, pulse is 100/min, and blood pressure is 130/80 mm Hg. He has diffuse coarse expiratory rhonchi in both lungs. Laboratory studies show: hematocrit 33%, white cell count 16,000/mm3, platelets 150,000/mm3, sodium 128 mEq/L, bicarbonate 24 mEq/L, BUN 24 mg/dL, creatinine 1.2 mg/dL, and glucose 140 mg/dL. The chest x-ray shows hazy interstitial infiltrates. Sputum Gram stain shows only white cells. What should be the next step in the management of this patient? (A) Transtracheal aspirates for Gram stain and culture (B) Oral antibiotics (C) Admit to hospital and start intravenous azithromycin and ceftriaxone (D) Do blood cultures and start on intravenous cefuroxime (E) Bronchoscopy Record # 58 A previously healthy 18-year-old woman presents to the emergency department with complaints of fever, chills, and bilateral lower extremity swelling for approximately 1 week. She has visited the emergency department three times over the last month. She was originally found to have a temperature of 101 F and an abnormal chest x-ray, with a WBC of 18,000/mm3 with 90% neutrophils and normal serum chemistries. She was treated with multiple courses of antibiotics but never really seemed to get better. Now she describes a persistent cough, abdominal pain, severe fatigue, and myalgias. Her dentist had treated her twice for "tooth infections" over the last two months. She remembers taking amoxicillin and clindamycin, respectively. Her physical examination today shows a temperature of 103 F, a pulse of 110/min, and a respiratory rate of 26/min. Her oxygen saturation is 96% on room air. She has left facial swelling and decreased breath sounds bilaterally. She has heme-positive, brown stool and slightly diminished strength in all extremities. She has edema of the lower extremities. Laboratory studies show the following findings: WBC: 22,000/mm3; hematocrit: 33%, platelets: 300,000/mm3; Na 136 mEq/L; K: 3.0 mEq/L; BUN: 62 mg/dL; creatinine: 3.8 mg/dL; C-ANCA: 1:160; P-ANCA negative; and ANA negative. Urinalysis shows: hemoglobin 3+, protein 2+, and erythrocyte casts. The chest x-ray shows a left lower lobe infiltrate. Which of the following is the most accurate statement? (A) Emergency dialysis is needed. (B) Cyclophosphamide and glucocorticoids result in markedly improved patient survival and renal function survival. (C) Cyclophosphamide and glucocorticoids result in markedly improved overall survival but does not alter course of renal disease. (D) TMP/SMX should be started prior to other modalities. (E) Glucocorticoid in pulse doses should be started as initial sole therapy.

Record # 59 A 40-year-old woman presents with orthopnea and a 1-month history of hemoptysis. She reports that today she coughed up 20 milliliters of blood. The symptoms have limited her level of activity. She denies chest pain or weight loss. She does not smoke or use intravenous drugs. She experiences intermittent palpitations at rest. Her past medical history is significant for rheumatic fever as a teenager, peptic ulcer disease, and iron-deficiency anemia. Her blood pressure is 130/70 mm Hg, pulse is 66/min, and the respiratory rate is 18/min. Her physical examination is remarkable for a low-pitched, mid-diastolic murmur at the left sternal border and a loud S1. There is a mild pitting edema of the lower extremities. The chest x-ray shows mild congestion with a prominent pulmonary artery and a straight, left cardiac border. An EKG shows a normal sinus rhythm at 80/min, right ventricular hypertrophy, and broad, notched P waves. What would be the next best plan of action for this patient? (A) Echocardiogram (B) Cardiac catheterization (C) Surgical evaluation for valve repair (D) High-resolution computerized tomography (CT) (E) Radionuclide ventriculogram (MUGA scan) Record # 60 A 52-year-old man presents to the emergency department with complaints of dyspnea, fever, headache, skin itching, and joint pains for the past four days. He noticed a decrease in his urine output as well. He denies pain on urination. He has a history of mild diabetes, which was diagnosed one year ago and is controlled with diet, and benign prostate hypertrophy. The patient has recently been diagnosed with a seizure disorder and has recently been started on phenytoin. His other medication is tamsulosin. On physical examination, the patient looks somewhat somnolent and cannot clearly state the present date. His temperature is 101.4 F, blood pressure is 168/88

mm Hg, respiratory rate is 25/min, and pulse is 98/min. The examination is significant for a pinkish, generalized maculopapular rash, jugulovenous distention, and basilar rales two thirds of the way up bilaterally. The throat is normal. Cardiac sounds are normal, and the abdomen is soft with no pain on palpation. There is no costovertebral angle tenderness. White cell count 13,400/mm3, neutrophils 78%, lymphocytes 16%, eosinophils 8%; hematocrit 38.6%; sodium 137 mEq/L; potassium 5.9 mEq/L; bicarbonate 18 mEq/L, BUN 156 mg/dL; creatinine 9.5 mg/dL. Urinalysis shows many red cells, white cells >50/hpf, protein 2+, and white cell casts. What is the best initial therapy of this patient? (A) Methylprednisolone (B) Vigorous hydration (C) Hemodialysis (D) Cyclophosphamide (E) Plasma exchange Record # 61 A 56-year-old man presents to your office complaining of fatigue and persistent joint pain for three months. His past medical history is significant for hypercholesterolemia, hypertension, and hepatitis C from injection drug use in the distant past. He has not been treated for hepatitis. He has no drug allergies. His physical examination is remarkable for a right ventricular heave and a soft holosystolic murmur at the right sternal border. His abdomen is soft, with a liver edge palpable three centimeters below the costal margin and splenomegaly. There are purpuric lesions on his skin. There is no joint deformity or muscle atrophy. Laboratory studies reveal the following: Hemoglobin 12 g/dL; platelets 410,000/mm3; BUN 47 mg/dL; creatinine 3.2 mg/dL; glucose 130 mg/dL, serum bicarbonate 20 mEq/L; total bilirubin 1.2 mg/dL; AST 88 U/L; ALT 110 U/L. C3 and C4 levels are low. Rheumatoid factor is positive at a high titer. Urinalysis -- protein 3+, hemoglobin 1+, with 50 red cells and no white cells or casts. Immunofluorescence of the renal biopsy shows large glomerular intracapillary deposits, with granular subendothelial deposits outlining the glomerular capillary walls. What would be the next appropriate step in the management of this patient? (A) Kidney transplant (B) Hemodialysis (C) Prednisone (D) Interferon and ribavirin (E) Cyclophosphamide Record # 62 A 40-year-old man returns to the office because of sinusitis that did not respond to a second course of antibiotics. At this time, he also complains cough, shortness of breath, and malaise. On physical examination, his temperature is 37.7 C, pulse is 88/min, respiratory rate is 18/min, and blood pressure is 110/65 mm Hg. You notice slight left eye proptosis. There is also mild tenderness over the maxillary sinuses. On auscultation of the lungs, there are bilateral basilar crackles. The heart examination is normal. Laboratory values reveal: WBC 10,500/mm3, hematocrit 37%, platelets 440,000/mm3. Urinalysis shows protein 2+, and red cell casts are present. The chest x-ray shows multiple bilateral infiltrates with cavities and hilar adenopathy. C-ANCA is positive. Which of the following statements is true? (A) This patient has an increased risk of malignant lymphoma (B) Chronic nasal carriage of Staphylococcus aureus has been reported to be associated with a higher relapse rate of the disease presenting here (C) The presenting disease is more common among blacks (D) If the disease does not involve the kidney, the sensitivity of C-ANCA increases from 70 to 90% (E) Pulmonary tissue obtained by thoracotomy is less specific than biopsy of the upper airway Record # 63 A 38-year-old woman presents with pain in both wrists and fingers for the past six months. She was previously started on NSAIDs and initially improved; however, now she comes back with worsening joint pain and the new onset of low back pain for the last two weeks. She has difficulty getting out of bed and has morning stiffness. She has a temperature of 99.4 F. Both hands have distal interphalangeal joint swelling and wrist tenderness. She also has pitting and onycholysis of the nails. On her scalp she has small, several, two-centimeter, scaly lesions. Her lower back is nontender. On laboratory examination, she has a hematocrit of 34% and an ESR of 60 mm/h. Her HLA-B27 is positive with a negative rheumatoid factor. X-rays of the hands and wrists show periosteal new bone formation along the shafts of metacarpals. She is started on a new medication and sent home. She comes back after two weeks with worsening of the joint pains and exfoliative skin lesions on the scalp. What are these symptoms most likely caused by? (A) Gold salts (B) Hydroxychloroquine (C) Sulfasalazine (D) Methotrexate (E) Steroids Record # 64 A 43-year-old woman comes to your clinic complaining of weakness and tingling of her lower extremities bilaterally over the last several days. Several years ago, she experienced an episode of blurry vision that resolved spontaneously. An MRI of the brain shows multiple, periventricular, white-matter lesions. What is the next step in the management of this patient? (A) Interferon beta-1b (B) Oral prednisone (C) High-dose intravenous steroids (D) Amantadine (E) Glatiramer acetate

Record # 65 A 56-year-old woman with a history of heart failure and dilated cardiomyopathy from ischemic heart disease presents to your office complaining of fatigue. She denies chest pain or palpitations. She was started on a minimal dose of carvedilol three weeks ago. She tolerated it well, and you were able to increase the dose of this medication. Currently, she is taking a maximal dose of lisinopril and carvedilol. However, after the last adjustment of her medications, she gained 3 kg and has increased shortness of breath. Today her heart rate is 78/min and her blood pressure is 110/80 mm Hg. On physical examination, the patient has mild jugulovenous distension, and there is no evidence of peripheral edema. EKG shows normal sinus rhythm and nonspecific ST changes. Which of the following is the most appropriate next step in the management of this patient? (A) Refer for transplantation evaluation (B) Start furosemide (C) Initiate therapy with digoxin (D) Stop carvedilol (E) Decrease the dose of carvedilol Record # 66 A 65-year-old man presents to the hospital with complaints of chest pain of 8 hours' duration. The EKG reveals anterior wall ST elevation. The patient receives aspirin, oxygen, tissue-plasminogen activator, metoprolol, and intravenous nitroglycerin. His symptoms resolve, and serum chemistries reveal a peak CPK of 1,200 U/L and a CKMB of 80 U/L. The patient is transferred to the CCU. His subsequent hospital course is uneventful until Day 3, when the patient develops severe dyspnea. The blood pressure is 120/70 mm Hg, and the heart rate is 120/min. Physical examination reveals a new, loud, holosystolic murmur radiating to the axilla and bilateral rales. What would be the most appropriate initial intervention at this point? (A) Heparin alone (B) Heparin and furosemide (C) Heparin and digoxin (D) Sodium nitroprusside (E) Surgery Record # 67 A 43-year-old man comes to the office seeking medical advice. His father was diagnosed with gout at the age of 45 years and now needs hemodialysis. His older brother is 50 years old and was diagnosed with gouty arthritis last year. The patient's past medical history is significant for hypertension, which is managed with atenolol. On physical examination, the patient is slightly obese. There are no obvious joint deformities. His range of motion is not restricted. The only significant finding on physical examination is some nodularity on palpation of the Achilles tendon on the left. His serum uric acid is 18 mg/dL (normal 2.5-7.5 mg/dL), and his urine uric acid is 850 mg/24 h (normal <800 mg/24 h on a regular diet). Treatment with allopurinol is started. In two weeks, the patient comes back complaining of a diffuse erythematous rash and itching. What is your next step? (A) Stop allopurinol (B) Stop atenolol (C) Desensitization to allopurinol (D) Give colchicine if an attack develops (E) Repeat the uric acid level in one month Record # 68 A 65-year-old homeless man with a past medical history significant for alcohol abuse was brought to the emergency department by the local ambulance company after being found outside the local strip mall being loud and reckless. Although he was awake, the patient was unable to give any further history. He is well known to the emergency department for multiple visits for alcohol intoxication. Four hours later, the patient was found to be unarousable even after vigorous noxious stimulation. His temperature is 97.9 F with a blood pressure of 110/65 mm Hg, a heart rate of 88/min, and a respiratory rate of 28/min. His eye examination is normal. He has bilateral rales on lung examination, with a minimally distended, nontender abdomen. His arterial blood gas shows: pH 7.15, pCO2 23 mm Hg, and pO2 88 mm Hg. Laboratory studies reveal: sodium 133 mEq/L, chloride 107 mEq/L, serum bicarbonate 10 mEq/L, BUN 34 mg/dL, creatinine 2.2 mg/dL, and glucose 180 mg/dL. The ethanol level is 46 mg dL, with a serum osmolality of 305 mOsm/kg. Urinalysis shows no protein, ketones, or white cells, but crystals are present. What is the definitive treatment for this patient? (A) Pyridoxine and thiamine (B) Fomepizole (C) Hemodialysis (D) Ethanol infusion (E) Gastric lavage Record # 69 A 72-year-old woman comes to the emergency department with 40 minutes of severe substernal chest pain. The pain does not change with respirations or bodily position. She has never been in your hospital before. She has a history of hypertension and diabetes for which she is maintained on an ACE inhibitor. Physical examination shows a normal blood pressure. There are no abnormalities found on physical examination. An EKG shows a left bundle branch block. She was given an aspirin to chew on her way into the emergency department. Which of the following will benefit this patient the most? (A) Metoprolol (B) Thrombolytics (C) Nitrates, morphine, and oxygen (D) Lidocaine (E) Low molecular weight heparin Record # 70 A 67-year-old man presents to the emergency department with dyspnea that has been worsening over the last 2 to 4 days. His chest x-ray shows a large pleural

effusion. After admission to the hospital, treatment with diuretics produces only a minimal response in his respiratory status. He undergoes a thoracentesis, which did not improve his symptoms. He quit smoking 3 years ago but had a 120-pack-year smoking history until then. Currently, he has a temperature of 100..3 F and a respiratory rate of 24/min. He has dullness to percussion three-quarters of the way up on one side. Laboratory studies on the pleural fluid show: LDH 1, 505 mg/dL, white cells 500/mm3, red cells 1,030/mm3, and glucose level 76 mg/dL. No bacteria is seen on Gram stain, and the pleural fluid has a pH of 7.5. The cytology is positive for malignant cells. Repeat chest x-ray shows a large pleural effusion on one side. What is the next best step in the management of this patient? (A) Serial thoracentesis (B) Video-assisted thoracoscopy (C) Chemotherapy and radiotherapy (D) Pleurodesis with doxycycline (E) Chest tube placement Record # 71 A 40-year-old obese African American woman is found to have developed a severe, uniform, erythematous, desquamatous rash, fever, increased liver function tests, and eosinophilia. The patient looks toxic. The patient has a past medical history of renal insufficiency secondary to poorly controlled hypertension, migraine headaches, gout, and systemic lupus erythematous. The patient is on a number of medications to treat her various illnesses. Which of the following medications is the most likely cause of these symptoms? (A) Amlodipine (B) Prednisone (C) Sumatriptan (D) Allopurinol (E) Colchicine Record # 72 A 57-year-old Greek man presents to your office for an initial visit. He has no symptoms and feels generally well. He has no past medical history and denies taking any medications. On physical examination, there is no jaundice, and his abdomen is soft and nontender. Blood pressure is 110/70 mm Hg; and pulse is 76/min. Rectal examination shows guaiac-negative, brown-appearing stool, and there is no evidence of hemorrhoids. Laboratory studies reveal the following: Hemoglobin: 10.6 g/dL Hematocrit: 32% Platelets: 350,000/mm3 MCV: 65 FL RBC: 6.8 million/mm3 (normal 4.2-5.9 million/mm3) Reticulocyte index: 2.8 RDW: 14% (normal 13-15%) What is the most accurate test to confirm your diagnosis? (A) Complete iron studies (B) Bone marrow biopsy (C) Peripheral smear (D) Hemoglobin electrophoresis (E) Colonoscopy Record # 73 A 25-year-old man presents to the clinic with diarrhea and abdominal pain for one day after eating with his family at a restaurant. He also admits to having generalized aches in his lower extremities for the past several weeks. Two weeks ago, he had an upper respiratory tract infection with coryza and a sore throat, which has subsided. Upon examination, he has a temperature of 100 F, a macular rash on the face, purpuric skin lesions on both the lower extremities and back, and minimal tenderness around both ankles with no soft tissue swelling. Urine analysis shows proteinuria, red cell casts, and hematuria. The stool guaiac is positive. BUN is 43 mg/dL, and creatinine is 3.7 mg/dL. What is the most accurate method of diagnosis? (A) Skin biopsy (B) Serum IgA levels (C) Response to prednisone (D) Renal biopsy (E) 24-hour urine Record # 74 A 62-year-old man is brought to emergency department after being found unresponsive by his wife in their apartment an hour ago. According to the wife, the patient has a history of anxiety and difficulty sleeping, which are being treated with diazepam. He also has depression, which is well controlled with imipramine. The patient uses metoprolol for hypertension and acetaminophen for "aches and pains." He is unresponsive to verbal stimuli. The withdrawal response to painful stimuli is sluggish, and there is occasional muscle twitching. The skin is flushed, and there are dry mucous membranes. The pupils are constricted, and the gag reflex is absent. The temperature is 101 F, with a heart rate of 59/min, a respiratory rate of 9/min, and a blood pressure of 85/50 mm Hg. The oxygen saturation is 85% on room air. The chest, heart, and abdomen examinations are normal. The EKG shows a widened QRS. The patient was intubated by the paramedics and was given administered dextrose, thiamine, and naloxone. What is the best management for this patient? (A) Administer flumazenil, acetylcysteine, and sodium bicarbonate and induce vomiting (B) Administer sodium bicarbonate and perform gastric lavage (C) Give bolus of saline, acetylcysteine, sodium bicarbonate, and charcoal (D) Administer flumazenil, acetylcysteine, normal saline, and charcoal (E) Provide supportive care for the patient and wait for him to recover Record # 75

A 34-year-old woman presents with complaints of asthma, which is worse at night. She has been using an albuterol inhaler with some relief of symptoms. She has a history of heartburn. On occasion, she uses famotidine, which she says improves her heartburn and asthma. She wonders if she needs the albuterol inhaler. What would be the most accurate test to evaluate if her asthma is related to gastroesophageal reflux disease? (A) Upper endoscopy (B) Barium swallow (C) 24-hour ambulatory esophageal pH (D) Esophageal manometry (E) Overnight nuclear medicine scan Record # 76 A 25-year-old woman with known multiple sclerosis comes to your clinic complaining of urinary hesitancy. She states that her symptoms have begun gradually over the last 3 months and have progressively worsened. Cystometrics show bladder hypertonicity with sphincter dyssynergy. What is the treatment of choice for this patient's symptoms? (A) Oxybutynin (B) Oxybutynin and intermittent bladder catheterization (C) Amitriptyline (D) Bethanechol (E) Amantadine Record # 77 A 34-year-old woman is admitted with one week of hemoptysis, a low-grade fever, and a 15-pound weight loss over the last two months. There are no chills or night sweats. She uses trimethoprim/sulfamethoxazole (Bactrim) intermittently for recurrent respiratory tract infections. Currently, her temperature is 100 F with a heart rate of 92/min, a respiratory rate of 18/min, and a blood pressure of 138/82 mm Hg. Her chest has bronchial breath sounds on auscultation of the left upper lung field. Her BUN is 26 mg/dL, and creatinine is 2.0 mg/dL. The C-ANCA is positive. Chest x-ray shows a cavitary lesion in the left upper lobe. Her urinalysis shows 2+ proteinuria with 20-30 red cells/hpf, but no red cell casts. What is the most specific diagnostic test? (A) Bronchoalveolar lavage with transbronchial biopsy (B) Open lung biopsy (C) Renal biopsy (D) 24-hour urine protein and creatinine clearance (E) CT scan of the chest with needle biopsy (F) Nasal biopsy Record # 78 A 67-year-old woman presents to your clinic with a chief complaint of palpitations that occur on and off for the past week. She states that she has been experiencing this problem for many months, but the problem always resolved on its own and would only last for several minutes. Recently, the palpitations have become more frequent and are disturbing her daily routine. She has a past medical history of hypertension and diabetes and was diagnosed with atrial fibrillation two years ago. Cardioversion was attempted twice but failed, and she is now taking coumadin daily. Her blood pressure is 130/85 mm Hg, and the pulse is irregularly irregular at a rate of 110/min. The INR is 2.l. Which of the following is true for this patient? (A) Chemical ablation with alcohol is the next treatment of choice. (B) Chemical ablation with phenol is the next treatment of choice. (C) Tip catheter with standard radiofrequency at a tip temperature of 95 C is the next best step. (D) Tip catheter with standard radiofrequency at a tip temperature of 70 C is the next best step. (E) There is no need for treatment at this time. Record # 79 A 30-year-old woman with a history of infection with HIV and hepatitis C is admitted for right-knee swelling and pain, a low-grade fever, and cough. The right leg has been getting increasingly painful and swollen over the past few days. She was discharged three weeks ago from a different hospital with a diagnosis of tuberculosis. Her medications after discharge were rifampin, isoniazid, pyrazinamide, ethambutol, Bactrim, and fluoxetine. She does not remember the doses. Her temperature is 100.2 F, blood pressure is 145/92 mm Hg, and the physical examination is only remarkable for an erythematous, swollen, tender right knee. What is the most likely etiology of this problem? (A) Isoniazid (B) Pyrazinamide (C) Ethambutol (D) Interaction between fluoxetine and antituberculosis medications (E) Rifampin Record # 80 A 27-year-old woman seeks the advice of her primary medical doctor because of progressive swelling of the right knee. She also complains of mild rectal discharge and pain in her wrists and ankles. She is afebrile. She has some mild pharyngeal injection, and the lungs and abdomen are normal. There is no rash evident. Examination of the lower extremities reveals an erythematous and edematous right knee with tenderness over the tendon sheaths of the ankles and wrists. Which of the following procedures is most likely to yield a diagnosis in this patient? (A) Arthrocentesis and culture of the synovial fluid (B) Blood culture (C) Gram stain of the synovial fluid (D) Cervical Gram stain (E) Culture of the urethra, cervix, rectum, and pharynx